Toward a Mechanistic Understanding of LGBTQ-Affirmative Cognitive-Behavioral Therapy: Testing Treatment Mediators in a Randomized Controlled Trial with Young Gay and Bisexual Men

Introduction: Young gay and bisexual men (YGBM) face elevated risk for co-occurring mental (e.g., depression, anxiety), behavioral (e.g., substance use), and sexual (e.g., HIV-transmission-risk behavior) health challenges compared to their heterosexual peers. LGBTQ-affirmative cognitive-behavioral therapy (CBT) targets psychosocial pathways through which minority stress contributes to these disparities. We evaluated whether LGBTQ-affirmative CBT operates through these mechanisms.Methods: We analyzed clinical trial data from 254 HIV-negative YGBM (ages 18–35; 67.2% racial/ethnic minority) with mental, behavioral, and/or sexual health concerns, randomly assigned to receive LGBTQ-affirmative CBT or one of two control conditions: LGBTQ-affirmative community counseling or HIV testing and counseling. Using baseline and 4-, 8-, and 12-month follow-up assessments, trajectories of identity-specific (i.e., acceptance concerns, concealment motivation, and internalized stigma) and general (i.e., assertiveness, emotion regulation difficulties, rumination, self-esteem, and social support) psychological mechanisms were examined. Additionally, latent change score structural equation models tested whether these mechanisms mediated the relative impact of LGBTQ-affirmative CBT on depression, anxiety, substance use, HIV-transmission-risk behavior, or their co-occurrence.Results: LGBTQ-affirmative CBT was associated with early and enduring improvements in internalized stigma, emotion regulation, rumination, and assertiveness, but not greater than control. Changes in emotion regulation and assertiveness also consistently predicted reductions in all study outcomes. No indirect effects emerged in the mediation models.Conclusion: Identifying treatment mechanisms can maximize the efficacy of LGBTQ-affirmative CBT. Based on this study, universal processes such as assertiveness and emotion regulation difficulties may be promising candidate mechanisms. Future iterations of LGBTQ-affirmative CBT should aim to maximize improvements in these processes.